A nurse is caring for a patient immediately following endotracheal intubation.
Which of the following actions should the nurse prioritize to assess the patient for complications?
Auscultate lungs for the presence of breath sounds.
Determine that the pulse oximetry is greater than 95%.
Assess baseline level of consciousness.
Assess for the presence of circumoral cyanosis.
The Correct Answer is A
Choice A rationale
Auscultating the lungs for the presence of breath sounds is a priority action following endotracheal intubation. This helps to confirm correct tube placement and assess for complications such as a pneumothorax.
Choice B rationale
While it is important to ensure that the pulse oximetry is greater than 95% to confirm adequate oxygenation, this is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
Choice C rationale
Assessing the baseline level of consciousness is important, but it is not the priority action following endotracheal intubation.
Choice D rationale
Assessing for the presence of circumoral cyanosis can indicate hypoxia, but it is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A non-productive cough is not a definitive sign of inadequate drug therapy for tuberculosis. It could be a symptom of many other respiratory conditions.
Choice B rationale
Decreased shortness of breath is generally a positive sign indicating improvement in the patient’s condition. It does not necessarily indicate inadequate drug therapy.
Choice C rationale
The presence of positive acid-fast bacilli in the sputum after 2 months of treatment indicates that the tuberculosis bacteria are still present in the patient’s body. This suggests that the triple antibiotic therapy is not effectively eliminating the bacteria, thus indicating inadequate drug therapy.
Choice D rationale
Poor appetite is a common symptom of tuberculosis, but it does not specifically indicate the effectiveness or inadequacy of drug therapy.
Correct Answer is A
Explanation
Choice A rationale
Auscultating the lungs for the presence of breath sounds is a priority action following endotracheal intubation. This helps to confirm correct tube placement and assess for complications such as a pneumothorax.
Choice B rationale
While it is important to ensure that the pulse oximetry is greater than 95% to confirm adequate oxygenation, this is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
Choice C rationale
Assessing the baseline level of consciousness is important, but it is not the priority action following endotracheal intubation.
Choice D rationale
Assessing for the presence of circumoral cyanosis can indicate hypoxia, but it is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
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